Home | How do adolescents with ADHD use and interact with the internet?

16 Jan 2019

Dawson AE et al. J Adolesc 2019; 71: 119-137

A huge increase in the prevalence of technology throughout multiple aspects of daily life has led to a transformation in the way adolescents express themselves and interact with their peers, with a significant impact on their social function (Spies Shapiro, Margolin. 2015). Despite this, little is known about how adolescents with ADHD, who are generally prone to social difficulties, use technology to interact with their peers. Therefore, the aim of this study was to examine how teenagers with ADHD use the internet, assessing how online behaviours are associated with offline behaviours (Dawson et al. 2019).

Participants with ADHD* were recruited from the Bridges to Education Success for Teens (BEST) Project, which was a large cross-site intervention study conducted in Ohio and Pennsylvania in the US. The BEST Project was conducted across three different cohorts spanning 2015–2016, 2016–2017 and 2017–2018. Participants were asked to complete an online survey regarding their technology use, which consisted of three separate rating scales (Online Behaviour Demographic Questionnaire, the European Cyberbullying Project Intervention Questionnaire and the Sexting Questionnaire†). Teenagers’ Facebook behaviours were assessed by double-coding their Facebook account using the Mikami and Szwedo’s Facebook Coding Manual Participants. Double-coded entries were then combined into mean scores and Facebook timelines coded for the following indicators:

Friendship and activity indicators: included number of Facebook friends, total number of posts, the unique number of friends that posted on the participant’s timeline, and the “reactions” given to posts.

Content exchanged: included percentage of posts that were shared from external material, as well as those that shared accomplishments and/or contained inappropriate behaviour.

Relationship quality: connection codes that evidenced that participants and their friends were actually associated by a specific reference to previous or future meetings; percentage of posts containing emotional support or relational aggression.

Global codes: captured a general sense of all content within the coding period; four broad categories were rated on a 5-point Likert scale including narcissism, excessive self-disclosure, positive emotion and negative emotion.

Teen offline behaviour ratings: included the completion of a number of rating scales to self-assess a range of behaviours.

Parent offline behaviour ratings: included the completion of a number of rating scales for parents to assess a range of behaviours.

The majority of participants were males (72.4%), who primarily reported their ethnicity as non-Hispanic (86.3%) and their race as white (81.1%). Participants were either in the 9th (50.0%), 10th (36.2%) or 11th grade (13.8%), with a mean age of 14.48 years. All participants had a previous diagnosis of ADHD, with 58.2% diagnosed with combined ADHD presentation and 41.8% diagnosed with inattentive presentation. Most participants did not report taking medication (65.5%), but 32.4% reported taking stimulants.

The main results from the study were as follows:

Social networking use: 92.5% of participants reported going online daily, with 91.4% using social networking sites. Of these, Instagram was the most popular (81.1%), followed by Snapchat (79.2%), Facebook (67.9%) and Twitter (45.3%).

Sexting: Whilst the majority of participants (72.4%) reported never sending or receiving a sext, 17.2% and 25.8% reported sending and/or receiving a sext, respectively. Participants who had received a sext were more likely to send a sext (X2[1] = 25.64; p < 0.001; OR = 68.40).

Association between internet uses and online risk behaviours: Compared with participants who infrequently used Facebook, frequent users were at greater likelihood of interaction with weak social connections and a lower likelihood of interacting with family members. Online risk-taking behaviours were generally associated; for example, participants who reported receiving a sext were at an increased likelihood of being a cyber-victim (X2[1] = 8.44; p = 0.044; OR = 7.14) and cyber-aggressor (X2[1] = 6.55; p = 0.010; OR = 5.00). Similar results were reported for participants who reported sending a sext (cyber-victim: X2[1] = 9.07; p = 0.003; OR = 15.18; cyber-aggressor X2[1] = 12.99; p < 0.001; OR = 15.11).

Comparisons between online and offline behaviours: Relative to online risk behaviours, participants with higher parent-reported emotional dysregulation, as well as higher self-reported impulsiveness, risk-taking, anxiety and depression, were at increased likelihood of sending and/or receiving sexts. Similarly, teens with these parent- and self-reported symptoms, as well as parent-reported oppositional defiant disorder symptoms, were more likely to be cyber-victims and/or cyber-aggressors. On average, teens who reported using Facebook (and generally using it with greater frequency) had greater levels of self-reported anxiety, depression and parent-reported emotional dysregulation.

The authors stated that this was the first investigation to comprehensively explore the technology-mediated social interactions of teens with ADHD using multiple methods and measures. Despite this, this study was associated with a number of limitations. First, the study included a small sample size (increasing the likelihood of Type II errors) and included a large number of tests (increasing the likelihood of Type I errors), which may have confounded results; therefore, conclusions should be interpreted with caution. Furthermore, the study did not include a comparator group, which leaves unclear what factors are unique to the present sample versus generalisable to teens with ADHD. Finally, the nature of Facebook and other social networking sites makes it possible for users to cultivate their profiles by deleting posts upon reflection; therefore, posts that were coded as part of the study were only those approved by the participant to be observed by their network of peers.

Overall, this study suggested that teens with ADHD use technology in a similar way to the general population, but may be at increased risk of cyberbullying behaviours. Furthermore, using Facebook may be associated with online risks (e.g. weak online connections) and offline risks (e.g. poorer social skills and more internalising symptoms). The authors stated that future research should focus on exploring how to regulate, monitor and decrease teens’ online risk-taking behaviours. Clinicians should also consider including discussions of social networking sites as part of ADHD management strategies, and should perhaps consider screening teenagers who use Facebook with high frequency for other social or emotional difficulties.

*Study participants were diagnosed with ADHD using Diagnostic and Statistical Manual of Mental Disorders – 5th Edition criteria via empirically supported methods whereby self-, parent- and teacher-reports of ADHD impairment were collected via interviews and rating scales. Eligible participants included BEST participants eligible at treatment randomisation (N=186, of which n=92 received treatment and n=94 received control). Participants were excluded if they met criteria for specific co-occurring disorders, did not meet school attendance requirements or had an IQ of <70. All parents and teens provided their consent†Online Behaviour Demographic Questionnaire: adapted from the Pew Research Centre’s Internet, Science and Tech survey to focus specifically on social networking, but also assess participants’ general online access and activity; the European Cyberbullying Project Intervention Questionnaire: 7-point scale including 22 items, with victimisation (11 items) and perpetration (11 items) subscales; the Sexting Questionnaire: incudes 6 yes/no questions to assess if participants sent (3 items) or received (3 items) sexts to varying degrees of explicitness. Participants were further queried about sexting frequency, media used and basic information about the sender/recipient of the sext‡Sharing of external content was assessed by evaluating the content shared by the participants, as well as friends’ posts, on their timeline

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